character length restrictions indicate. I 1, TITLE OF RESEARCH TRAINING PROPOSAL (Do not exceed 56 charactet_, including spaces and punctuation.) CANCER SURVIVORSHIP 2. LEVEL OF FELLOWSHIP 13. PROGRAM ANNOUNCEMENT/REQUEST FOR APPLICATIONS Predoctorai IPA-00-068 4a. NAME OF APPLICANT (Last, First, Middle Initial) 14b. EMAIL ADDRESS 14c. HIGHEST DEGREE(S) Mordll, Edward, F lefm@e fmorrul.com I BA 4(t. PRESENT MAILING ADDRESS (Street, City, State, Zip Code) 4e.PERMANENMTAILINGADDRESS(StreetC, ityS, tate,ZipCode) Department of Psychology Department of Psychology Campus Box 3270, Davie Hall Campus Box 3270, Davie Hall Chapel Hill, NC 27599-3270 Chapel Hill, NC 27599-3270 4f. OFFICE TELEPHONE NO. 14g.HOME TELEPHONE NO. (Area Code, No, and Ext.) I (Area Code and No.) 919-962-3991 I 919-962-3991 4j. [] U.S. CITIZEN OR U.S. NONCITIZEN NATIONAL or 5. TRAINING UNDER PROPOSED AWARD (See Fields of Training) Discioline No" I Subcate(lorv Name" _ 6910 tOncology . I 7a. DATES OF PROPOSED AWARD 17B. PROPOSED AWARD From (MMIDDIYY): IThrough(MMIDDIYY): I(in months) 09/01/03 08/31/08 60 4h. PERMANENT PHONE NO. 14i, FAX NUMBER (Area 9C1od9e-9a6nd2-N3o9.)91 I (Area C9od1e9-a9n6d2N-2o,5) 37 r'] PERMANENT RESIDENT OF U,S, 16. PRIOR AND/OR CURRENT NRSA SUPPORT I (Individual or Institutional) 115[] NO [] YES (/f "Yes, " refer to itern 24, FormPage DURATION 18. DEGREE SOUGHT DURING PROPOSED AWARD IDegree: [Expected Completion Date: PhD 05/09/10 9. HUMAN 19a. RESEARCH EXEMPT 19b. HUMAN rc. SUBJECTS I [] NO [] YES I SUBJECTS _YES NO Ill Wes"ExemptioNno.: I ASSURANCE NO. I 1 la. NAME OF SPONSOR (Last, first, middle initial) Gil, Karen, M Telephone: (919) 962-3991 FAX: (919) 962-2537 Email: kgil@email.unc.edu 11c. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT i iPsychology 11 d, MAJOR SUBDIVISION iCollege of Arts and Sciences =i3: NAME AND TEL. NO. OF ADVISOR IF DIFFERENT FROM 11a. Telephone: NIH-DEFINED PHASE Itl CLINICAL TRIAL I10a. VERTEBRATE ANIMALS 110b. A;IsMuALRAWELF_E DNo DYES I[F]N]YOES r 11b. NAME OF PROPOSED SPONSORING INSTITUTION UNC - Chapel Hill AddressD: epartment of Psychology Campus Box 3270, Davie Hall Chapel Hill, NC 27599-3270 12, ENTITY IDENTIFICATION NO. DUNS NO. (if available) 1566001393A1 00-320-3213 14.NAMEOFOFFICIALINBUSINESOSFFICE Scott Blackwoocl Telephone9:19-962-3411 FAX: 919-962-5011 Name and address of institution where research training will take place if different from Item 11 b. T,_e: Acting Senior Dir. - Res. Adm. AddressO: ffice of Sponsored Research Address: CB #1350, 440 W. Franklin Street Chapel Hill, NC 27599-1350 Email: ResAdminOsr@unc.edu 15. APPLICANT CERTIFICATION AND ACCEPTANCE: I certify that the statements herein are true, complete, and accurate to the best of my knowledge, and I agree to comply with the terms and conditions of award if an award is issued as a result of this application. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. I certify that I have read the Ruth L Kirschstein National Research Service Award Assurance, that I wilt abide by the Assurance if an award is made, and that.the award will not support residency training.